Surgery May be Best Tx for Hashimoto's Disease

Thyroidectomy leads to significant improvement in chronic fatigue

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Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.

Patients diagnosed with Hashimoto's disease who underwent a complete thyroidectomy saw improvement in symptoms, most notably a reduction in severe fatigue.

Note that thyroidectomy surgery was associated with a drop in levels of anti-thyroidperoxidase (anti-TPO) from 2,500 units/L to <500 units/L in the surgery patients compared with about 3,200 units/L to 2,500 units/L among the patients treated medically.

Among patients with the autoimmune disorder of the thyroid who were treated with surgery, the percentage of those reporting severe fatigue was reduced from 84% at baseline to 34% at 18 months (P<0.001) while the percentage dropped from 85% to 75% (NS), said Ivar Guldvog, MD, PhD, of Telemark Hospital Trust in Porsgrunn, Norway, and colleagues.

"Eighteen months after randomization, the surgical group reports significant improvement in health-related quality of life and chronic fatigue, almost comparable to the background population," Guldvog said at his poster presentation at the International Thyroid Congress.

In addition, the authors found that levels of anti-thyroidperoxidase (anti-TPO) fell from 2,500 units/L to <500 units/L in the surgery patients versus about 3,200 units/L to 2,500 units/L among the patients treated medically. Serious exhaustion, pain, and stiffness in musculature and joints are correlated with elevated titers of anti-TPO.

Patients with Hashimoto's disease are often prescribed thyroxin, Guldvog stated. "However, thyroxin does not normalize symptoms or anti-thyroidperoxidase levels," he said.

"The fatigue experience with Hashimoto's disease is debilitating," Guldvog told MedPage Today. "People can't work. Their quality of life is very poor. Medical treatments fail to relieve all the symptoms, but complete surgical removal of the thyroid appears to be curative in most cases. Hashimoto's isn't a disease that you die of, but it can make your existence miserable."

Guldvog's group performed a pilot study and an interim analysis in an ongoing randomized study, both of which showed that "the antibodies and the symptoms disappeared in parallel when the thyroid gland was completely removed." Some of the patients in the pilot study have been free of relapse for as long as 11 years, he added.

The goal of the pilot study was to show that surgical treatment could be preformed without unacceptable complications, and "we succeeded in that," Guldvog said. The randomized multi-center trial has 75 patients undergoing surgery and 75 receiving medical treatment.

The current study had 97 patients who underwent complete thyroidectomy. Post-procedure, the anti-TPO levels normalized in a majority of patients and symptoms improved in more than 75% of patients after 36 months, Guldvog said.

"The patients remained free of symptoms for an average of 7 years of observation," he said. "The antibody titers fell further and well-being continued to improve during follow-up."

Patients were eligible for the trial if they had anti-TPO levels greater than 1,000 IU/L; if they had a hypothyroid state in need of thyroxin supplementation; and if they had accompanying complaints such as extreme fatigue, muscle and joint pain, or mucosal drying of the mouth and eyes.

Adverse events were uncommon in the study: none had hypocalcemia >4 months, and 2% had complications in the recurrent nerve.

"The results stimulate the hypothesis that Hashimoto is a surgical condition," the authors wrote, adding that they are in the middle of follow-up time for the randomized study.

"Most of these patients are already on thyroid replacement medication when we see them for surgery. They will continue on medication after the surgery," he said.

He pointed out that an ethics review board at his institution has now approved surgical treatment on younger patients with earlier disease.

Mitchell Austin, MD, a pediatric otolaryngologist at Florida Hospital and associate professor of medicine at the University of Central Florida, both in Orlando, said that when he does treat Hashimoto's patients, successful total thyroidectomy is possible "if we can get them early...during the course of Hashimoto's disease, there can be scarring of the thyroid, and that can make excision of the thyroid a more difficult operation," he said.

"This is a very difficult disease. Some of these people can become catatonic. They can be completely useless to themselves," he added.

Guldvog said that Hashimoto's patients are usually treated by medical doctors and are not usually referred to surgeons. "I have to recruit patients, and then the patients speak to each other and they ask for the surgery," he said.

Guldvog and co-authors disclosed no relevant relationships with industry.

Austin disclosed no relevant relationships with industry.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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